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Rethinking the term “Mental Illness”

In this country there is quite a debate raging about the idea of mental illness. The modern notion of mental health disorders such as bipolar disorder, attention deficit disorder and schizophrenia are psychiatric terms that have recently been created and codified in a series of books known as the Diagnostic and Statistical Manual (DSM), now in its fifth edition. The first DSM was published in 1952 and classified 106 conditions as mental disorders. The recent DSM V has over 300 different disorders.

The process of writing the DSMs involved the collaboration of many psychiatrists who pooled research and conceptual theories to discuss and then finalize these books. There has been a great deal of criticism towards these manuals, coming not only from groups that oppose psychiatry but from the psychiatric profession itself.

Here are the main points of contention:

1: The DSM lacks validity: There are no medical tests to determine the evidence of a psychiatric disorder. There is no specific test with biological markers for showing a sign of a particular disorder. The lack of pathophysiology makes the determination of an illness pattern a subjective call by a doctor. One of the most egregious examples was the inclusion (no longer present) of homosexuality as a mental disorder. The idea that homosexuality could be included undercuts the idea that the DSM presents a scientific approach to mental health. Thomas Insel, the director of the National Institute of Mental Health, recently stated

“The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever.”

2: The DSM lacks reliability: There is often a lack of consistency amongst doctors for diagnosing the same set of symptoms. That means that one person may be diagnosed as having schizophrenia while another would diagnose bipolar disorder. These often lead to competing treatment strategies as one doctor prescribes a certain set of psychiatric drugs while another doctor prescribes another.

3: Relationship between psychiatry and the pharmaceutical companies: There are major ties between the pharmaceutical companies and the psychiatrists who created the DSM. Approximately half of the doctors who have been involved with creating the diagnostic conditions in the DSM IV have also been paid by pharmaceutical companies to teach or lecture about particular drugs that are often used in the treatment of psychiatric conditions described in the DSM. Furthermore, most people who are diagnosed with a mental health condition are “treated” with a psychiatric drug. That means there is a financial incentive for pharmaceutical companies to expand the definition of “mental illness”. Today 20 percent of Americans are taking a psychiatric drug for some form of emotional distress. Sadly, the main advocacy group in the US, the National Alliance on Mental Illness (NAMI) is also largely funded by pharmaceutical companies.

4 Excessive Disorder Syndrome: There has been a remarkable explosion in the number of disorders categorized in the DSMs- From about 100 to over 300 today. The lead psychiatrist and author of the DSM IV, Allen Frances, has been particularly vocal about what he calls the “pathologization of normality”, meaning that we have started labeling normal human experience as a disorder. Some of the worst examples of these disorders are “Disruptive Mood Dysregulation Disorder” for temper tantrums and “Minor Neurocognitive Disorder” for forgetfulness in old age.

The DSM and Psychiatric Treatment

Because of these multifold problems, there are serious concerns about the scientific underpinnings of psychiatry. The DSM is used as the mental health Bible not only for diagnosing people but for treatment as well. We have increasingly become reliant on the prescription of psychiatric drugs for emotional distress. Pharmaceutical companies have heavily promoted the idea that their medicines can treat these “illnesses” as defined by the DSM. But there is serious concern that these ailments are being diagnosed improperly or excessively and in turn medications are being prescribed prematurely and without thought of alternative and more holistic ways of managing distress.

An example of this is the diagnosis of ADHD (attention deficit hyperactivity disorder) that was first mentioned in the DSM-III in 1987. This diagnosis is now given to just over one out of ten kids (11%) and the principle treatment strategy is the prescription of a stimulant such as adderall or ritalin. This begs the question do one out of ten kids really need to be on psychiatric drugs to manage their lives well?

Many in the field are beginning to speak up and say that we have shifted way too far towards a biological and drug based treatment approach to working with distress. There is increasing evidence that the major classes of psychiatric medications including antipsychotics, antidepressants, benzodiazapenes, stimulants and mood stabilizers can all have significant side effects and tend to cause long term health complications. There is also continuing evidence that many people who start medications can have a significantly hard time tapering off psychiatric drugs.

The problem with “Mental Illness”

So does “mental illness” exist? Certainly, people experience significant periods of distress, anxiety, depression, altered and extreme states. The question is, can all of these be defined as specific biological illnesses and do they need to be paired with treatment strategies that inevitably involve psychiatric drugs? In my way of looking at this question, I prefer to call these crises “emotional distress” as it tends to imply a shorter period of time and does not define a person as “mentally ill”, which implies a permanent and biological condition. Someone who is seen as mentally ill is seen as forever marked by a condition- and often in need of psychiatric treatment. “He is mentally ill” sounds far more pejorative and permanent than “he is experiencing emotional distress.”

Moving away from the term mentally ill also fits into a framework that distress is a normal human experience and does not necessarily require overwhelming intervention. In my view, most forms of emotional distress can be better helped by a model of gentle care, nourishment, rest, time and community support. As we have seen, the psychiatric DSM has fallen short and led to an excessive focus on labels and drug based treatment strategies. Instead of this excessive focus, we could do better by fostering wellness and nourishment models for helping people in distress.